Keywords:

Abstract

Service-user involvement is an essential component of mental health service provision. This review aims to synthesise literature that has attempted to elicit children's experiences of mental health services with particular reference to looked-after children. The review is limited to qualitative research with study inclusion based on a synthesis of good quality criteria. Identification of gaps in the literature, directions for further research and implications for service developments are discussed.

Introduction

Respect for children's views is enshrined in the Children Act (DoH, 1989), and the UN Convention on the Rights of the Child (1999). Guidelines advocate making ‘particular efforts’ to ensure that looked-after children, as a ‘frequently excluded group’, are encouraged and supported to give their views and be involved in all levels of decision making (DoH, 2002, 2004). Eliciting looked-after children's views of CAMHS is particularly important because of the nature and complexity of their difficulties (Mental Health Foundation, 2002). In principle looked-after children, like all children, should be afforded the status as experts in their own experience with a fundamental right to contribute to their own mental health care and service developments. The possibility that children may express views which are in conflict with developed guidelines is easy to overlook. For example, while DoH (1996) identifies the central importance of continuity of placement for looked-after children, without mentioning continuity of social worker, some researchers have reported children prioritising just this factor (Munro, 2001). A resolution of how to pragmatically resolve the competing principles of evidence-based practice (such as the NICE guidelines, in the UK) and children as informants on their own lives is beyond the scope of this paper. However, current trends supporting empirically-validated practice guidelines involve many complex issues: interventions identified by research as effective may be in conflict with the expressed preferences of children. This is particularly pertinent given the tendency in society to attach more value to the views of the highly educated. Clinicians need to maintain a reflexive position in this regard, for example as to whether internalised societal values predispose us to subjugate children's views over research evidence.

Listening and responding to looked-after children

Looked-after children often have insecure attachments which can influence the development of socioemotional development skills such as perspective taking abilities and willingness to trust adults (Golding et al., 2006). This may engender reluctance in clinicians to engage them in reflective discussions about services. Nonetheless, a number of studies have demonstrated that, given sufficient support, vulnerable children can provide feedback on the services they receive (Mudlay & Goddard, 2006; Dance & Rushton, 2005; Potter, Holmes & Barton, 2002; Thomas & Beckford, 1999; Prior, Lynch & Glaser, 1999, 1995). Given these circumstances, some clinicians have described the need to guard against an ‘all or nothing’ approach, in which children are either given full responsibility or not consulted (Wolpert et al., 2001; Golding et al., 2006). Rather one aims for a balance between children's needs (for protection) and their rights (to have their views respected). Furthermore in some situations children may not want the burden of decisions but nonetheless wish their views taken into account. In essence, listening and responding thoughtfully to looked-after children's views is likely to be complex but achievable.

Methodology

Search methods

Articles were identified via searches on electronic databases, citation and reference searches, and contact with authors of relevant publications. Due to the paucity of studies focusing specifically on looked-after children, those which also included other children were reviewed. Groups that shared a number of similarities with looked-after children (e.g. experienced abuse or adopted) were considered particularly relevant.

Inclusion criteria

To address publication bias unpublished studies were included only if they demonstrated sufficient quality. Quality control was based on a synthesis of six papers providing quality criteria (Charmaz, 2004; Parker, 2004; Harden et al., 2004; Malterud, 2001; Elliot Fischer, & Rennie, 1999; Turpin et al., 1997). This produced 12 themes: context, credibility checks; critiques; data analysis; data collection; examples; internal validity; remaining faithful to the data; reflexivity; sample; theories; and relevant literature. No study met all aspects of each theme. Whilst all themes were considered, any study giving a clear description of the sample and evidence that themes emerged from the data (rather than preconceptions) were included.

Findings of children's views of mental health services

Thirty-nine studies were identified, of which 14 met inclusion criteria (Table 1). This represented the views of over 200 children. Despite the range of ages, gender, presenting difficulties and orientation of services, analysis identified eight common themes.

1. Perceptions, evaluations and recollections of interventions (studies 1–13). Children were able to provide valuable information about the services they received, which were balanced (including positive and negative comments). Their perceptions also altered in ways consistent with the therapeutic process. Taken together with research demonstrating vulnerable children (including looked-after children) were able to meaningfully comment on important aspects of their lives, there is consistent support for guidelines recommending consulting with looked-after children at all levels: in their individual treatment and service provision discussions.

2. Personal qualities, skills, and attitudes of staff (1, 2, 3, 5, 6, 7, 8, 11, 12, 14). The primary importance of individual contacts was a recurring theme in the studies including personal attributes (e.g. kind, approachable), the sense of something being done, and respect for confidentiality. Taken together these data suggested that participant's experience of being heard and understood could be the foundation for a good match between child's need for action and therapeutic responsiveness. This implies that, despite NICE guidelines focusing on intervention type, other aspects of staff interactions may be more important to children. These aspects may cut across therapeutic orientation and may be important for staff training. This is consistent with literature suggesting therapeutic orientation might be secondary to other factors in distinguishing effective therapies (Stiles, Shapiro & Elliot, 1986). The importance of attending to the way that staff relate to children is likely to be particularly significant for looked-after children, given that children's responses to staff may well be influenced by previous damaging interactions with adults (Golding et al., 2006, Hughes, 2004)

3. Therapy process (3, 5, 6, 7, 8, 11, 12, 14). Children could meaningfully comment on the therapeutic process, identifying aspects that they felt were helpful and unhelpful, including particular techniques - analogous to adult clinical populations (Llewelyn et al., 1988). For many children talking was a source of challenge and discomfort as well as being helpful and valuable. Consistently across modalities and age groups, the value of non-verbal interactions (e.g. drawing, and playing) in enabling children to be engaged in therapy was acknowledged. This included the adoption of a variety of strategies to manage difficult situations. Excepting play therapy, play and other non-verbal communications were frequently regarded as relegated activities rather than central and rarely mentioned in guidelines for good practice. This theme suggests a more central importance, reflected in the training of mental health professionals. The use of dolls in paediatric services to explain procedures is an example of good practice that could be built on. Considering looked-after children, representing attachment relations is important - key to which is the use of guided and non-verbal techniques such as drawing and story-stem methodologies (Binney & Wright, 1997; Goldwyn et al., 2000). Implications for working therapeutically with foster families includes; alerting clinicians to find ways of enabling foster-family members to think about their use of different communication modalities. An example of good practice from CBT/systemic orientation is given by Hobday, Kirby and Ollier (2002), suggesting exercises incorporating non-verbal elements to undertake with foster and adoptive families.

4. Practical arrangements and physical surroundings (2, 3, 5, 11). Both physical surroundings and practical arrangements, including quality of play materials, cleanliness of environment, and general management of sessions, are an important therapeutic feature. These factors were given more significance by children than is often reflected by services despite many identified as key NHS targets. For looked-after children services paying attention to high quality physical surroundings and the importance of practical arrangements may be especially pertinent, echoing Bruno Bettleheim (1950).

5. Desire for inclusion (7, 8, 11, 13, 14). Children value meaningful involvement in their therapy, and in decisions about their treatment. Some participants offered helpful and constructive suggestions as to how their participation and inclusion could be facilitated. Clearly inclusion of children in decision making is complex and needs to balance children's rights and adults responsibilities as discussed above. However, in principle children's inclusion should be actively pursued at all levels.

6. Outcome of intervention (3, 4, 5, 6, 9, 11, 14). Children in the studies consistently reported overall therapy outcomes positively. Therapy during childhood was frequently appraised as having helped, both at the time and at least in one study retrospectively in adulthood. However, as in general mental health work, more objective assessments suggest the ratio of helpful to unhelpful outcomes is more mixed. The most straightforward interpretation of these data is that it represents a bias in sampling, which suggests that adopting purposeful sampling of a group of children who experience a poor outcome or a longitudinal cohort sample would be fruitful avenues for future research.

7. Suggestions and improvements (2, 4, 8, 13). Young people proposed improvements in service delivery including better access to therapies, more information and that their suggestions are received with due respect and consideration. These proposals mirror government guidelines. The implications are particularly important for looked-after children where past experiences with adults may have been a source of denigration or abandonment (Hughes, 2004). A useful general principle might be that suggestions are valued but undertaken such that decision-making responsibilities reflect the child's best interests (Golding et al., 2006).

8. Social context (4, 7, 9). Across a number of studies children acknowledged the relevance of social context and awareness of pertinent social processes inherent in homogenous groups: both the advantageous (such as support from those sharing similar experiences) and disadvantageous (social stigma). This raises the issues of public awareness and media representations of mental distress in children in society. Increasing awareness of mental health problems in schools, analogous to anti-bullying projects, may offer a solution. Looked-after children with mental health difficulties face the double stigma of being a ‘child in care’ and having a ‘mental illness’. Research into the impact of positive media representations, such as in the children's TV programme/novel ‘Tracey Beaker’ (Wilson, 1991) may offer important insights for raising public awareness.

Vulnerable children's views on mental health services

No studies were found that exclusively investigated looked-after children's experiences of mental health services. Seven studies included vulnerable children's (looked after, adopted or abused) views about mental health services, in most cases as part of a larger study. Of these, two had sufficient rigour/relevance to warrant inclusion (14, 15). Three categories emerged, based on the views of 20 children. The findings need to be interpreted with caution.

Ambivalence towards professional intervention. Participants felt wary of professionals and uncared for, yet some children described positive relationships with specific staff members and appeared to appreciate that there was a more deep-seated purpose to the intervention than to make them feel good. This fits in with suggestions above regarding the importance of considering how to effectively build relationships with looked-after children in services, potentially over particular therapeutic techniques.

Ambivalence towards talking. Participants expressed both a desire to talk and the difficulty of doing so. Trust and a degree of control in choosing what to talk about were highlighted as helpful to facilitate talking. This echoes the general theme of therapy process above.

Non-verbal communication. Vulnerable children identified the value of non-verbal communication, in facilitating engagement in therapy. This again echoes the more general theme above.

Conclusions

Drawing on studies utilising qualitative methodologies enabled a view of mental health services ‘through the eyes of children’ as advocated by the Department of Health (2004). The themes reflected important aspects of services to them. In support of DoH guidelines advocating service-users involvement, children, including vulnerable children with support, are able to comment on their therapy and experience of mental health services. They are able to provide balanced views that prove useful in decision making both on individual and service wide levels. Moreover, children are keen to be involved. The marked ambivalence towards mental health services expressed by vulnerable children was not evident in studies of other children. Due to the lack of studies this finding needs to be interpreted cautiously. The paucity of studies in which the voices of looked-after children are heard suggests they are frequently excluded from contributing in this way. Looked-after children's views need to be sought, heard and respected. It is, however, imperative that within this process professionals remain responsible for ensuring that decisions are taken which are in the child's best interests. Doing so, may sometimes represent a conflict or compromise with the child's expressed suggestions.

Implications for practice

Eliciting looked-after children's views of their mental health service should be standard practice: both in individual treatment and in service development discussions. The implementation of this is likely to require attention to a number of issues. For example, it cannot be assumed that looked-after children are non-defended respondents and where extreme idealised or denigratory representations of services are reported other aspects of the wider context need to be considered for example as attachment organised positions (Hughes, 2004). This is in line with current practice within qualitative narrative methodologies (Smith, 2004; Hollway & Jefferson, 2000). Paying particular attention to building relationships with looked-after children is as integral to the intervention as the techniques/theories used. This is particularly pertinent given the potential ambivalence for these children concerning involvement of mental health services in their lives. In practice this may require additional resources and enablers such as supervision, staffing and reflective space. However, there remain unresolved dilemmas regarding the most appropriate way to facilitate the development of more functional attachment patterns in looked-after children (within the therapy setting versus facilitating unmet relationship needs within the foster care relationship context). Focussing on building relationships with children in clinical practice is also likely to raise the current public-sector tensions between evidence-based and researchable approaches e.g. techniques and theories, versus what helps individuals, which may be more difficult to describe and investigate (Wright & Richardson, 2003). Utilising non-verbal communication enhances the ability of mental health services to meaningfully engage looked-after children. Therefore having a variety of approaches for inviting exploration of issues encompassing a range of modalities including play, arts, story telling, sculpting may facilitate open reflections on service-based experiences. There are a number of good examples that can be drawn from other areas of practice. Arguably this also includes the therapist's intuitive impressions at a counter-transference level. Finally, appropriate thought should be given to children's experiences of practical arrangements and physical surroundings within which they receive mental health services. There have been examples of good practice within other institutional settings where checklists have been utilised as aide-memoirs and audit tools to ensure quality in this domain is maintained. In the spirit of service-user involvement expert service users could also be regularly invited in to feedback on these issues.

Directions for future research

Throughout this review a number of gaps in the research literature have been identified. Filling these might include the qualitative explorations of looked-after children's experiences. Given the paucity of research in this area using a qualitative methodology seems valuable since it offers thick descriptions of phenomenology which in turn enables meaningful hypothesis generating from which larger scale quantitative research projects can develop. Qualitative approaches are also productive ways of ensuring participant's views are represented at the outset. Future research using the concept of satisfaction could be extended by drawing on mixed methodology or the themes described above to incorporate aspects of CAMHS which are important in how children experience a service for example using them to develop nomothetic satisfaction ratings scales for CAMHS.

Future research eliciting children's views of mental health services should include or indeed purposively sample children, who are of primary school age, or younger, since this age group is currently underrepresented in the available literature. In addition, there is a need for studies that elicit the views of children who experience a poor outcome from therapy, such as purposeful sampling of this group or a longitudinal cohort sample. Finally, a potentially new avenue for research is investigating the impact of media representations of foster care and psychological distress on children's views.

Finally it is important to acknowledge the enormous difficulties that are encountered in gaining consent to engage looked-after children in research. This is multi-factorial: the procedure for gaining consent in social service settings tends to be less defined than in health settings. Some readers may find this surprising as one could hardly describe experiences of coping with the requirements of NHS Research Ethics Committees as a wholly positive one! (See for example MacPherson et al., 2005). For research purposes the general concept of the ‘state as parent’ poses significant problems for locating responsibility within bureaucratic organisations such as child services. Consequently the requirement is for researchers to track-down and engage multiple party consenters (foster-carers, birth parents, social services and the child)– a logistical nightmare. If looked-after children's views are ever going to gain significant representation within research contexts the above problems need to be addressed as soon as possible, for example by one centralised ethical decision-making body in loco-parentis.

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